Clinical Progress Note: Point-of-Care Ultrasound for the Pediatric Hospitalist

Three recent meta-analyses found favorable operating characteristics when using POCUS for the diagnosis of pneumonia in children, with summary sensitivities of 93%-94% and specificities of 92%-96%.^1-3 However, these meta-analyses were limited by high heterogeneity due to the inclusion of multiple different care settings and the use of variable reference standards and sonographic criteria for diagnosing pneumonia. POCUS is superior to chest radiography for evaluating parapneumonic pleural effusions,⁴ allowing for rapid identification of loculations, fibrin strands, and proteinaceous material, and for serial bedside evaluation of effusion size and characteristics.

Additional advantages of POCUS include avoidance of ionizing radiation and the potential for cost and time savings. Two studies demonstrated reductions in radiography use and improved cost, although they were not conducted on hospitalized patients. One randomized controlled trial (RCT) conducted in a pediatric emergency department (ED) demonstrated a 38.8% reduction in chest radiography use without increasing the ED length of stay (EDLOS), antibiotic use, or unscheduled follow-up visits.⁵ A retrospective matched cohort study conducted in another pediatric ED reported that when compared with patients evaluated by chest radiography, those evaluated by POCUS had significantly shorter EDLOS (−60.9 min) and mean health systems savings ($187 per patient).⁶ We believe that POCUS has value in the evaluation and management of pneumonia and parapneumonic effusions, although further studies investigating patient outcomes and involving inpatient populations are required.

POCUS can augment the physical examination, helping to both avoid unnecessary incision and drainage (I+D) procedures and detect drainable fluid collections. Abscess is suggested when hypoechoic material without vascular flow is detected, and although other structures such as vessels, cysts, and lymph nodes can mimic skin abscesses, this is a relatively straightforward examination for clinicians to learn.

Two meta-analyses found that POCUS had high sensitivity for diagnosing skin abscesses in the ED.^7,8 A pediatric subgroup analysis conducted in a study by Barbic et al. found a sensitivity and a specificity of 94% (95% C: 88%-98%) and 83% (95% C: 47%-97%), respectively.⁷ Subramaniam et al. included six studies (four pediatric) with 800 patients (653 ≤ 18 years old) and found an overall pooled sensitivity of 97% (95% C: 94%-98%) and a specificity of 83% (95% C: 75%-88%).⁸ No subgroup analysis was performed, but the included pediatric studies reported sensitivities and specificities between 90%-98% and 68%-87%, respectively.

Although POCUS performs better than physical examination for the diagnosis of drainable abscesses, evidence regarding patient outcomes is mixed. A retrospective review from four pediatric EDs found that integration of POCUS lowered treatment failure rates, defined as any incision and drainage (I+D) or surgical manipulation after discharge from the initial ED visit (4.4% vs 15.6%, P < .005).⁹ A single-center retrospective cohort study found that POCUS reduced EDLOS by a median of 73 minutes (95% C: 52-94 min) when compared with radiology-performed studies.¹⁰ The aforementioned study conducted by Barbic et al. found that in pediatric studies, POCUS led to a change in management (eg, whether or not to attempt I+D) in 14%-27% of patients.⁷ However, a multicenter prospective observational cohort study involving seven pediatric EDs found that despite changing the management in 22.9% of cases, POCUS was not associated with any statistically significant differences in treatment failure rates, EDLOS, discharge rates, use of sedation, or use of alternative imaging.¹¹ These studies were limited by a lack of randomization or control group and emphasize the need for RCTs that measure patient outcomes. Future studies should investigate how POCUS can be used in inpatient settings both for initial diagnosis of drainable abscesses and for serial evaluation of evolving phlegmon or incompletely drained collections.